1. Make Every Mouthful Matter Dietitians - SSOTP Make Every Mouthful Matter

2. Aim of session Share the Staffordshire Nutrition Support Guidelines. Discuss making every mouthful matter - what is food fortification? why bother? Consider whether current puree/ soft diet provided in you care home is nutritionally complete? Ensure appropriate use of supplements Make Every Mouthful Matter

3. Make Every Mouthful Matter Whose responsibility is good nutrition?

4. 6 Steps to Appropriate Nutritional Care – Staffordshire Nutrition Support Guidelines Make Every Mouthful Matter 1.Identification of Nutritional Risk (Calculate MUST) 2.Assess the underlying cause of malnutrition 3.Set clear treatment goals and document in the patient record 4.Make every Mouthful Matter – offer food first advice 5.Review – Prescribe oral nutritional supplements if no change 6.Treatment goal met? Review and discontinue oral nutritional supplements

5. 6 Steps to Appropriate Nutritional Care – Staffordshire Nutrition Support Guidelines Make Every Mouthful Matter Step 1 - Identification of Nutritional Risk (Calculate MUST)

6. Equipment required for adequate screening Calibrated scales - preferably seated – Class III MUST tool information Food and fluid charts Measuring tapes Make Every Mouthful Matter

7. Malnutrition Universal Screening Tool - MUST Looks at body weight, height and percentage weight loss Rapid or regular weight loss is a cause for concern BMI under 18.5 should prompt investigation BUT may be normal for this person Make Every Mouthful Matter

8. Add Scores together BMI Score + Weight Loss Score + Acute Disease Effect Score =MUST Score (probability of being malnourished) Follow Staffordshire Nutrition Support Guidelines to develop care plan and to give advice Make Every Mouthful Matter

9. Subjective Criteria In some patients - may not be possible to obtain height, weight or BMI In these circumstances: Other subjective criteria can be used to assist your professional judgement of the patient’s nutritional risk category This is not designed to assign a score Make Every Mouthful Matter

10. Mr Brown 80 year old man Weight 50kg, Height 1.7m, BMI 17.3kg/m² Recently in hospital following a stroke Speech and language therapist advised - pureed diet and thickened fluids In the last month since returned to home has lost 5kg MUST score = 3 Make Every Mouthful Matter

11. 6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines Step 2 – Assess the underlying cause of malnutrition Ability to chew and swallowing issues Impact of medication Physical symptoms e.g. nausea, vomiting, constipation Environmental and social issues Psychological issues Tissue viability/ skin integrity Make Every Mouthful Matter

12. 6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines Step 3 – Set clear treatment goals and document in the patient record Target weight or target weight gain/ BMI Wound healing if relevant Weight maintenance where weight gain is unrealistic Make Every Mouthful Matter

13. Consider what the treatment goals could be for Mr Brown? Make Every Mouthful Matter

14. 6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines Step 4 – Make every mouthful matter 3 fortified meals – 2 snacks – 1 pint fortified milk Make Every Mouthful Matter

15. Fortifying meals – Full fat milk – Skimmed milk powder – Cream – Butter/margarine/oil – Cheese – Sugar/honey/jam/syrup – Peanut butter/Nutella – Mayonnaise/salad cream Make Every Mouthful Matter

16. 1 pint of fortified milk per day Fortified milk = 1 pint full fat milk with 4 tablespoons skimmed milk powder added Gives 600kcal and 40g protein in 1 x pint Use in milkshakes/ smoothies Malted drinks, tea, coffee made with whole milk Make Every Mouthful Matter

17. Ordinary Diet Food EatenCaloriesProtein BreakfastPorridge (milk and water)1355 Mid morningCoffee151 LunchVegetable Soup and roll2207 Mid afternoonTea151 DinnerPoached fish, 1 x scoop mash, peas, tinned peaches 27031 SupperCoffee151 Total67046 Make Every Mouthful Matter

18. Adapted Diet Food EatenCaloriesProtein BreakfastPorridge (made with full-fat fortified milk) 3308 Mid morningMilky Coffee (200ml fortified milk) 20013 LunchCream of Vegetable Soup and roll with butter 3358 Mid afternoonTea and biscuit852 DinnerPoached fish, 1 x scoop fortified mash, peas, tinned peaches 49032 SupperMalted Drink with 200ml fortified milk 22513 Total166576 Calorie Difference 99530 Make Every Mouthful Matter

19. Pureed diets Make Every Mouthful Matter

20. Pureed diets Evidence shows that average intake of people given an unfortified pureed diet is about 800kcals/day Make Every Mouthful Matter MenWomen Energy - EAR2100kcals1810kcals Protein - RNI53.3g46.5g COMA report Dietary reference Values for food Energy and Nutrition in the UK for older people Caroline Walker Trust – Eating well for older people Caroline Walker Trust – Eating for older people with dementia

21. What do consumers think of pureed food? (2014). Journal of Nutrition in Gerontology and Geriatrics, 33:139-159. -Food are indistinguishable from one another. -Variety is lacking. -Inconsistent appearance/texture. -Want “special” food for birthdays & celebrations. -Want to eat in private. Make Every Mouthful Matter

22. Improving Pureed Diets Make sure a pureed diet is clinically necessary. Make food as attractive as possible. – Piping bag or food moulds. – Vibrant colour combinations. – Use sauces (eg. cranberry sauce; raspberry coulis). Maximize the flavour of food (eg. condiments). Make Every Mouthful Matter

23. Improving Pureed Diets Make sure staff know what the foods are and can describe them to the resident. Use recipes to promote a consistent product. Provide a choice for sauces and condiments. Vary the temperature of the foods and the flavour (eg. sour, tangy) Make Every Mouthful Matter

24. High Calorie Liquids for Pureeing Sauces –cheese, parsley, dill, tartar, cheesy tomato or white sauce Creamy soups Full-fat fortified milk Full-fat yoghurt or greek yoghurt Crème Fraiche/double cream/sour cream Coconut milk (tinned) Make Every Mouthful Matter

25. Don’t forget about snacks! -Use soaking solutions for bread, cream crackers, biscuits and cake. -Pureed fruit or pure juice. -Custard -Smoothies or milkshakes -Ice cream & jelly (only if allowed unthickened fluids). Make Every Mouthful Matter

26. 6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines STEP 5 – Review: If food first approach has failed – prescribe oral nutritional supplements Assuming patient fits prescribing criteria Make Every Mouthful Matter

27. Comparison of Products Milk shake style supplements, 330 calories and 13g protein V ½ pint fortified milk, approx 300 calories and 20g protein Crème pudding, 125g pot, 171 calories and 7g protein V Thick and creamy yoghurt, 125g pot, 200 calories and 7g protein Juice based supplements, 300 calories, 13g protein V 1 x pint orange juice – 300 calories Vitamin and mineral intake should be considered Make Every Mouthful Matter

28. 6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines STEP 6 – Treatment goal met – review and discontinue Review regularly to monitor Assess continued need for supplements When goals of treatment met discontinue oral nutritional supplements Make Every Mouthful Matter

29. How to Refer to Dietetics Stafford Dietitians: Stafford and Stone, South Staffs, Cannock See referral Form Tel: 0300 1240109 Sir Robert Peel Dietitians: Tamworth, Lichfield – See Referral Form Tel: 01827 263800 Waistlines : Cannock, Stafford and Surrounds, South Staffs, Lichfield, Tamworth, East Staffs – See Referral Form Tel: 01543 509740 University Hospitals North Midlands Staffordshire Dietetic Team: Royal Stoke University Hospital: 01782 676030 East Staffordshire: Burton-on-Trent - See Referral Form - Tel: 01283 507 160

30. Staffordshire Nutritional Support Guidelines and referral forms http://www.staffordshireandstokeontrent.nhs.uk/ Services/e.htm Make Every Mouthful Matter